Optimal Investigation Procedures Under Selected PSRO Policies

This article presents a methodology for utilization review which aids the local Professional Standards Review Organization (PSRO) in selecting optimal timing of Concurrent Stay certification by diagnosis. This procedure is accomplished by modeling patients' admissions, inpatients stays and discharges for each diagnosis as a stochastic process which is audited under the PSRO by three utilization review techniques: preadmission, concurrent and retrospective review. The timing of concurrent stay certification is determined so that the maximum benefits are derived for the utilization review cost expended. The methodology presented here is a tool to aid local PSRO management in determining the most cost-beneficial utilization review process to be utilized in their jurisdiction. It is not an attempt to demonstrate the effectiveness of our utilization review policy over another in general. On the contrary, while the model is generalizable to every PSRO, the utilization review policies resulting from any application are situation-specific. The major contributions of this article are new insight into modeling the utilization review process and the provision of a methodology for which computer programs exist and are readily available to any PSRO that should desire to determine its utilization review procedure in this cost-benefit framework. In order to apply the model it is necessary that certain parameters specific to the application site be estimated or assumed. Exact procedures to aid the PSRO in parameter estimation is the subject of current investigation.